Provider Demographics
NPI:1689961120
Name:KIM, KI WAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KI WAN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 VISTA WAY
Mailing Address - Street 2:SUITE #202
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-4559
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3601 VISTA WAY
Practice Address - Street 2:SUITE #202
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4559
Practice Address - Country:US
Practice Address - Phone:760-439-1871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-05
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA635071223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program